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Difficulty: MediumPhysiological Adaptation

Following a surgical repair of a fractured tibia 24 hours ago, a 65-year-old client suddenly develops severe restlessness and acute confusion. The client's respiratory rate has increased to 24 breaths per minute. Which action should the practical nurse take first?

  1. Obtain a pulse oximetry reading and auscultate the client's breath soundsAnswer
  2. B
    Review the admission documentation to check for a history of dementia
  3. C
    Administer the prescribed as-needed opioid analgesic to promote comfort
  4. D
    Document the observations and plan to recheck the vital signs in one hour

Answer

The practical nurse should first obtain a pulse oximetry reading and auscultate the client's breath sounds.
In any sudden clinical deterioration, the nurse must prioritize Airway, Breathing, and Circulation (ABCs). Restlessness, agitation, and acute confusion are early indicators of hypoxia. A client who recently underwent surgery on a long bone (such as a tibia) is at high risk for complications like a fat embolism or pulmonary embolism. The nurse's immediate priority is to assess the client's oxygenation status before initiating other actions.

Step-by-Step Solution

1
Analyze the clinical data provided in the scenario.
The client has a long bone fracture, new onset of severe restlessness, acute confusion, and an elevated respiratory rate.
Identifying the client's risk factors and acute symptom changes is necessary to determine the physiological urgency of the situation.
2
Apply the ABC (Airway, Breathing, Circulation) prioritization framework.
The symptoms point toward a potential compromise in oxygenation (Breathing/Circulation), possibly due to a respiratory complication like a fat embolism.
The ABC framework dictates that physiological needs, specifically airway and oxygenation, must be addressed before pain management or cognitive baseline checks.
3
Select the immediate nursing intervention that addresses the highest priority need.
Gathering objective data regarding the client's respiratory status is the most immediate priority.
Data about the client's oxygenation is required to confirm hypoxia and guide prompt emergency interventions or provider notification.

Key Concept

Recognizing early signs of hypoxia and prioritizing respiratory assessment (ABCs) in postoperative orthopedic clients.
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Topics

Physiological Adaptation

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